Managing Cancer That Has Spread To The Bones
- When prostate cancer spreads, it most commonly goes to the bones of the axial skeleton, which includes areas like your spine, pelvis, and ribs.
- Bone metastases can lead to pain, weakness, and difficulty with daily activities, and they can also affect overall health, but it’s important to remember that there are still many treatment options today.
- For prostate cancer that has spread, hormonal therapy plays a key role in treatment. Additional therapies — like radiation, chemotherapy, and pain medications — will be tailored to your individual case.
- In recent decades, the role of radiation in treating advanced prostate cancer has evolved. It can be used to help with symptoms and disease control.
- “If a man has prostate cancer and it has spread, radiating their prostate can lead to improvements in their quality of life. It can prolong the duration that their treatments, like hormonal therapy or chemotherapy might work, and in some men may even help them live longer,” Dr. Daniel Hamstra, chair of radiation oncology at Baylor College of Medicine in Houston, tells SurvivorNet.
When prostate cancer spreads, it most commonly goes to the bones of the axial skeleton, which includes areas like your spine, pelvis, and ribs. These bone metastases can lead to pain, weakness, and difficulty with daily activities, and they can also affect overall health. However, it is crucial to remember that effective treatments exist to manage these symptoms and improve your quality of life.
Read MoreFinding The Right Treatment Path
As previously noted, treatment for advanced prostate cancer typically involves combining hormone therapy, also known as androgen deprivation therapy (ADT), with drugs called androgen receptor pathway inhibitors (ARPIs), and sometimes also chemotherapy.Clinical trials have repeatedly shown that these combination therapies significantly improve survival outcomes and can even lead to a better quality of life by more effectively reducing symptoms like pain and fractures.
Systemic therapy is a cornerstone of managing bone metastases. These treatments work throughout your body to control the cancer and slow its progression, which in turn can help reduce your symptoms.
“It gives patients a chance to get more tests done, perhaps genetic tests or genomic tests. It gives patients a chance to understand how the hormonal therapy is going to affect their lives. It gives us a chance to see how well the hormonal therapy is working,” Dr. Hamstra explains.
“Then, radiation therapy to the prostate or to individual lesions can be done when we add the next generation or second generation of hormonal therapy. Sometimes that’s done prior to radiation. Sometimes that’s done after radiation,” he adds.
Dr. Hamstra notes that treatment typically will not involve adding other drugs like chemotherapy or PARP inhibitors at the same time as radiation. “So if people are planning on chemotherapy and radiation, typically that would be done either before or after the radiation, but not at the same time.”
Many modern systemic therapies for metastatic castration-resistant prostate cancer (mCRPC), such as abiraterone/prednisone, enzalutamide, Radium-223 (Ra-223), docetaxel, and cabazitaxel, have been shown to reduce skeletal-related events (SREs) and improve bone pain and overall quality of life.
What Are Skeletal-Related Events?
While bone metastases can sometimes be present without symptoms, especially early on, they can eventually lead to complications that need treatment. These complications are often called “skeletal-related events” (SREs).
The most common symptom you might experience from bone metastases is pain. This pain typically starts subtly and gradually worsens over weeks to months, often described as an aching sensation, similar to a toothache.
However, sometimes the pain can come on suddenly, especially if it’s due to a pathologic fracture (a break in a bone weakened by cancer). If the metastases affect your spine, nerve root entrapment can occur, causing a burning or radiating type of pain.
It’s common for individuals to attribute new aches to other causes, like arthritis or muscle strain, but it’s vital to have new or worsening bone pain investigated, even if you think it’s from something else.
Pain Management (Analgesics)
When cancer has spread to the bone, managing pain is a top priority.
There are a wide range of medications that can be used, including:
- Opioids (often a mainstay for painful bone metastases)
- Adjuvants (like nonsteroidal anti-inflammatory drugs or NSAIDs)
- Osteoclast inhibitors (bone-modifying agents like bisphosphonates)
Radiation Therapy For Advanced Prostate Cancer
Dr. Hamstra, who has been caring for men with prostate cancer for more than 20 years, notes that the role of radiation therapy in treating advanced disease has evolved a great deal in that time. While radiation therapy to the prostate gland itself was historically not pursued in cases of advanced prostate cancer, this practice has more recently changed in some cases.
“We’ve now learned from a number of good clinical trials that … if a man has prostate cancer and it has spread, radiating their prostate can lead to improvements in their quality of life. It can prolong the duration that their treatments, like hormonal therapy or chemotherapy might work, and in some men may even help them live longer,” he says.
When cancer has only spread to a small number of areas, a condition known as oligometastatic prostate cancer, radiation to metastatic sites can also play a key role.
“Radiation of those individual small areas can be a quick, outpatient procedure. It is painless, is highly effective, and again, can often prolong the duration of the therapy and, in some cases, may even improve survival,” Dr. Hamstra explains.
External Beam Radiation Therapy (EBRT)
If your bone pain is not responding well to systemic therapy and is limited to one or a few specific areas, EBRT is typically the treatment of choice.
It uses focused radiation to target the painful area and can be very effective in relieving pain. Often, a single high dose of radiation (8 Gy) to the affected area is sufficient for most patients.
EBRT can be used for:
- Treating painful bone metastases
- Controlling local progression in the prostate
- Managing oligometastatic disease (a limited number of metastatic sites)
- Enhancing outcomes when used with systemic treatments
EBRT is non-invasive and typically well-tolerated. It’s especially effective for palliative purposes, such as alleviating pain or preventing fractures in bones affected by cancer.
Bone-Targeted Radioisotopes
Unlike EBRT, radiopharmaceuticals are radioactive substances that are injected into the bloodstream and travel throughout the body to target cancer cells. These agents deliver internal radiation directly to tumor sites.
These are special radioactive medications given intravenously that travel through your bloodstream and are preferentially absorbed by areas of active bone metastases. They deliver targeted radiation directly to the cancer cells in the bone. These are often considered for men with multiple osteoblastic bone metastases, especially if they are symptomatic.
Pluvicto
Lutetium Lu-177 vipivotide tetraxetan, a PSMA-targeted radioligand therapy known by the brand name Pluvicto, is a newer, FDA-approved option for patients whose cancer is PSMA-positive (meaning it expresses a protein called PSMA, which can be seen on a specific type of PET scan).
Lutetium-177 is a radioactive substance attached to a molecule that binds to PSMA-positive cancer cells, delivering targeted radiation directly to the tumor. This can be for both bone metastases and non-bone (soft tissue) metastatic sites.
As of March 28, 2025, the FDA expanded the use of Pluvicto for adults with PSMA-positive mCRPC who have been treated with an androgen receptor pathway inhibitor (ARPI) and are eligible to delay chemotherapy.
This is a major step forward.
Before this, Pluvicto was only available for patients who had already undergone chemotherapy. Now, it can be used earlier, before chemo is required, tripling the number of eligible patients and giving many more men the chance to access this innovative therapy.
Studies have shown it improves overall survival and time to progression compared to standard care in this setting, often with a more favorable side effects profile than chemotherapy.
Xofigo
Radium-223 (brand name Xofigo) is another option for men with symptomatic mCRPC who have bone metastases only (no evidence of spread to internal organs like the liver or large lymph nodes).
Xofigo is a form of radiation that is given through an IV and selectively targets cancer that has spread to bones. Studies have shown to improve overall survival and reduce symptomatic SREs compared to best supportive care.
While effective, Xofigo can sometimes permanently reduce your bone marrow reserves, which might limit your ability to receive certain cytotoxic chemotherapies in the future. Due to this concern and the benefits of Pluvicto, Pluvicto has largely replaced Xofigo in areas where it is available.
Questions To Ask Your Doctor
- What sort of systemic therapy should I be on?
- Will I need to combine different treatments?
- How will my symptoms or side effects be controlled?
- Does radiation have a role in my treatment plan?
Content independently created by SurvivorNet with support from Novartis Pharmaceuticals Corp.
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